Menopause and Menopausal Problems
Menopause is part of a gradual biological process (except when surgically induced), culminating in the cessation of ovulation and menstruation. In the three- to five-year period preceding a woman’s final menstrual period (known as perimenopause), her ovaries produce less and less estrogen and progesterone, the two major female hormones. (Together with two other female hormones, known as follicle-stimulating hormone and luteinizing hormone, estrogen and progesterone orchestrate ovulation, menstruation, and if fertilization occurs, pregnancy.)
During perimenopause, menstrual periods may become irregular or unusually light or heavy. Ovulation (the monthly release of an egg) becomes less frequent and eventually stops.
The cessation of menstruation usually occurs at approximately age 50. Menopause is considered complete when a woman has been without a period for a year. Some women reach this point in their early 40s, others not until their late 50s. Neither is abnormal. (If a woman ceases to menstruate before the age of 40, it’s not considered true menopause, but premature ovarian failure, though the results are the same.)
Although menopause is clearly associated with a number of physiological symptoms, it’s a myth that menopause causes clinical depression or psychosis. Some women do feel angry and depressed, of course, and do experience mood swings. Those suffering from night sweats and other troublesome symptoms may be irritable from lack of sleep. At midlife, too, women may be coping with professional and marital problems, may be dealing with adolescents, or may be assuming responsibility for the care of grandchildren or older relatives. All this might contribute to depression. But the influence of hormone deficiencies on emotions is a matter of debate. A number of studies suggest that women with young children are more likely to be depressed than menopausal women.
When it comes to health, more important than the immediate symptoms of menopause are its long-term consequences. Today, once a woman enters menopause, she can expect to live almost another 30 years - years that can be productive and rewarding. Yet once her supply of estrogen decreases markedly, her risk of two serious diseases increases dramatically. One of these is heart disease. Before menopause, few women die of heart attacks. After menopause, women begin to catch up with men in rates of heart disease; by age 75, rates become similar. At age 65 the same number of women die of heart disease as of cancer, and after age 75, heart disease is the chief cause of death among women.
Postmenopausal women also find themselves at increasing risk of osteoporosis, the bone-thinning disorder that can eventually result in disabling fractures. Women begin life with less bone mass than men, and after menopause, bone loss among women is more rapid than it is among men. That is why, after age 65, so many women suffer from osteoporosis.
Women need to be aware of these increased risks and to take steps—ideally, well before menopause - to prevent them.
Symptoms of Menopausal Problems
For many women the only sign of menopause is the end of menstrual periods, preceded by irregular periods and changes in the amount of blood flow. Other common signs or symptoms that some women experience include the following.
- Hot flashes, or hot flushes, often accompanied by profuse sweating
- Vaginal dryness, genital atrophy or thinning of the vaginal walls
- Stress incontinence
- Mood swings, depression, and sleep problems are reported by some women, but there is widespread disagreement as to whether emotional changes and sleep disturbances are the result of menopause.
What Causes Menopausal Problems?
Natural menopause is a normal biological shift that probably starts in a woman’s mid- to late 30s, when estrogen and progesterone levels begin a very gradual decline—a process that accelerates at some point after age 40. (Estrogen production does not completely stop. The ovaries still produce a little, as do fat cells and the adrenal glands.)
Women who have never had children tend to reach menopause earlier. Ethnicity, marital status, genetics, and geography don’t seem to influence menopause. Smokers, however, experience menopause, on average, two years earlier than nonsmokers, though no one understands why.
Women who have hysterectomies (surgical removal of the uterus) experience an abrupt cessation of menstruation, though their ovaries continue to produce hormones. If their ovaries have also been removed, they experience an abrupt menopause, which may cause more-severe symptoms than a naturally occurring one.
What If You Do Nothing?
Menopause is a natural transition in a woman’s life, not a medical condition or a health problem. But estrogen and progesterone play many roles in a woman’s body, affecting many tissues, including the breasts, skin, vagina, bones, blood vessels, and digestive system, in addition to the reproductive organs. When production of these important hormones declines, many changes, both short- and long-term, are to be expected. However, menopausal symptoms vary considerably from one woman to another. Many women have occasional and/or mild symptoms that are largely tolerable without any sort of intervention. Other women experience symptoms that are so severe that medical advice or treatment is required (though symptoms usually diminish over time).
About 75 percent of American women experience hot flashes—sudden feelings of intense heat, accompanied by a flushed face and, often, sweating, and followed by a clammy feeling. Sometimes an aura precedes the flash—you sense that you’re going to have one. Heart rate increases, and your body temperature fluctuates. All this is caused by a shortage of estrogen, which is somehow involved in regulating body temperature (though no one understands how).
By day, hot flashes can be embarrassing and disconcerting, and they can result in sweat-soaked clothing. By night, hot flashes or night sweats (hot flashes accompanied by sudden sweating) can disrupt sleep. A woman may awaken several times a night in sweat-soaked sheets and feel exhausted the next day.
But even in one woman, hot flashes vary in intensity, frequency, and the span over which they occur. Because estrogen production fluctuates as it diminishes, hot flashes can come and go. Some women have them for a month and never again. It’s also possible to have hot flashes for months, then have them disappear for months, only to recur. But hot flashes do subside over time: only 20 percent of women experience them four years after menopause.
Another common consequence of menopause is vaginal dryness—a reduction in vaginal lubrication (usually accompanied by thinning of the vaginal walls) that may lead to pain during sexual intercourse. This, rather than the decline in estrogen, is a primary reason for reduced sexual desire in menopause. A decline in testosterone levels also plays a role.
The decline in estrogen can cause the cells lining the urinary tract to thin and the muscles that control urine flow to weaken. Consequently, some women experience urinary incontinence. Some women are also more prone to urinary tract infections because of changes in urinary tract mucosa and vaginal bacteria.
Home Remedies for Menopausal Problems
If hot flashes are disrupting your life, you should certainly see a doctor. Hormone replacement therapy (HRT) can put a stop to hot flashes and night sweats, and can correct vaginal dryness. However, it isn’t appropriate for everyone.
Medical science knows little about nondrug or dietary remedies for hot flashes, vaginal dryness, and other menopausal symptoms. The herb black cohosh is promoted as a menopausal remedy, but its effectiveness is questionable and can also have side effects. The following self-care measures may prove helpful and they are certainly safe.
- Dress in layers. Start with a porous fabric like cotton next to your skin. Avoid woolens. If a flash starts, take off the top layer. Try drinking a glass of cold water or juice if a flash is beginning.
- Sleep comfortably. Sleep on cotton sheets, and keep your bedroom cool. Layer your sheets and blankets so that you can remove a layer if you have a flash.
- Monitor your diet. Alcoholic beverages and highly spiced foods seem to induce hot flashes in some women.
- Exercise. Some women have found that regular exercise helps ease hot flashes. Exercise can also help you sleep better.
- Try tofu—it can’t hurt. Plants contain estrogenic compounds that resemble (but are not identical to) human estrogens. One estrogen “family,” called isoflavones, occurs in high concentration in soybeans and the soybean product tofu. Whether isoflavones in soy or plant estrogens in other foods are effective against hot flashes isn’t proved, but certainly tofu is a good addition to a healthy diet. If you want to try it as a hot-flash remedy, get the real thing, rather than soy drinks, which are not as high in isoflavones. Supplements containing soy isoflavones are not recommended, since it’s hard to be sure what they actually contain and what their hormonal effects are. Large doses of isoflavones might cause hormone imbalances that increase the risk of certain cancers.
- Be patient. The problem won’t last forever. Hot flashes are worse right at menopause. They usually subside and may go away entirely within three to five years.
- Treat vaginal dryness. A seeming loss of sexual desire may in fact be due to this condition, which can make intercourse painful. Vaginal creams containing estrogen or nonestrogenic water-soluble lubricants can alleviate vaginal dryness. Many women, happy to be liberated from birth control and worries about pregnancy, report an increase in sexual pleasure in their 50s. Although ovulation may occur less regularly as a woman approaches menopause, she may still be able to get pregnant. If you are certain you don’t want to become pregnant, it’s important to use a reliable method of contraception until you are clearly past menopause.
- Avoid alcohol, spicy food, coffee and chocolate. Alcohol, spicy food, coffee and chocolate can cause hot flushes.
HRT: Points to Consider
Millions of women age 50 and older take take some form of hormone therapy—either estrogen replacement therapy (ERT) or hormone replacement therapy (HRT), a combination of low-dose estrogen and progestin. It’s been known for some time that replacing estrogen after menopause can help relieve symptoms of menopause. In addition, there has been persuasive evidence that estrogen replacement can also reduce the long-term risk of osteoporosis (thinning bones) as well as heart attack and other forms of cardiovascular disease.
But the results of studies have left researchers—and the public—with a nagging feeling of uncertainty about the cardiovascular benefits of hormone therapy. Studies have generally shown that hormone therapy has positive effects on HDL (“good”) cholesterol levels in postmenopausal women—but the benefit has varied. In one study, HRT had positive, but lesser, effects than ERT—yet far more women take HRT because ERT increases the risk of endometrial cancer, while HRT does not.
In addition, there continue to be concerns about whether long-term hormone therapy (10 years or more) increases the risk of breast cancer.
Therefore, hormone therapy for healthy postmenopausal women continues to be controversial. What does seem clear is that no one solution is right for all women—and that many women do very well without hormone therapy.
Only you, in consultation with your doctor, can decide if HRT (or ERT) is appropriate for you. Here are some points you should both consider:
- Are you having severe hot flashes or other menopausal symptoms? Taking hormones can relieve them. If your symptoms are mild, however, you may prefer to manage without medication.
- Do you have a family history of osteoporosis or other risk factors for the disease? Hormone therapy is known to reduce the risks for this crippling disease, or at least to help delay its onset.
- Do you have a family or personal history of breast cancer? If the answer is yes, you may be advised not to undertake hormone therapy, although its effect on breast cancer risk is by no means clear. Short-term use of hormones (five years or less) does not appear to raise breast cancer risk—nor does it offer benefits against heart disease and osteoporosis. If you decide on long-term therapy, you might wait to begin until you are in your sixties: You could still get the benefits and then stop after 10 years in order to limit your breast cancer risk.
- Do you have varicose veins, or a history of blood clots or of gallbladder or liver disease? Are you obese? If so, you may not be a candidate for hormone therapy.
- Are you willing to tolerate possible side effects of hormone therapy such as spotting, monthly bleeding, or breast tenderness? (Some combinations of estrogen and progesterone administered continuously may not produce bleeding.)
- Are you willing to be on a regimen of medication for many years? (You can take hormone therapy for a short period, but when you stop, you cease to receive its benefits.)
- If you are taking hormone therapy for the long term, the cost can be an issue.
If you are at risk for heart disease, this may be another reason to consider hormone therapy. However, the actual benefit isn’t clear. Moreover, whether or not you take hormones, it’s vital to live a healthy life if you want to lower your risk of any chronic disease. Our recommendations for preventing a heart attack and preventing osteoporosis offer additional ways to protect yourself.
Menopause is a normal consequence of aging. But some of the troubling symptoms and health consequences (such as osteoporosis) associated with menopause can be prevented or delayed with hormone replacement therapy.
Beyond Home Remedies: When To Call Your Doctor
When you first experience changes in your menstrual patterns—either irregular periods or unusually light or heavy blood flow—it’s a good idea to see your doctor to make sure the changes are related to menopause and not caused by a medical problem. (You still need to have regular gynecological checkups that include a Pap smear). Also see your doctor if you miss a period or you experience vaginal bleeding between periods.
What Your Doctor Will Do
To rule out medical problems associated with abnormal menstrual bleeding, your doctor will perform a pelvic exam. A Pap test may show the effect of low estrogen levels on the vaginal lining (mucosa). There are also tests and measurements designed to reveal hormone levels in the blood and urine. If you are at risk for osteoporosis, your doctor may also recommend testing your bone density. You and your doctor will also evaluate your personal and family histories to decide whether or not you would benefit from HRT.
The Complete Home Wellness Handbook
John Edward Swartzberg, M.D., F.A.C.P., Sheldon Margen, M.D., and the editors of the UC Berkeley Wellness Letter
Updated by Remedy Health Media